SOL (Space occupying lesion) of brain
33-year-old female underwent an episode of dizziness followed by speech disturbances and some right hand weakness. Her physical exam showed very mild signs of right cerebelar dysfunction. The MRI found mid-Vermian Cavernoma with clear signs of past bleeding and Bulging into the fourth ventricle. A surgery for resection of the cavernous malformation was recommended.
1. Preferred treatment?
2. Urgency and type of surgery?
Problems and diagnosis
SOL (Space occupying lesion) of brain
Female, 33 years old, Israeli born
Current Illness – History
Generally healthy 32-year old, not taking any medication.
About 10 days ago, started to suffer from dizziness, which increased when sitting.
About 1 week ago, started suffering weakness in right arm, and was unable to write.
Also, 2 days before, the patient noticed deficits in her speech.
No headaches, vomiting, cramps, disturbed gait, or double vision.
Patient went to Emergency Room at Barzilai hospital where they did a head CT which showed a space occupying lesion in the posterior fossa.
Does not smoke, no drugs, no alcohol, no sleep problems, not physically active.
Results from measurements taken in Emergency Room
Measurements all normal
Breathing normally (room air)
Results at admission
Temp: 36.7ºC Pulse: 74 Blood pressure: 115/68 Weight: 45kg
Height: 162cm Approx BMI: 17.15kg/m2 Approx body volume: 1.45m
Fully conscious and aware. GCS 15. Pupils equal and reactive to light. Eye movements normal. No nystagmus. No Parinaud’s. No facial paralysis. No loss of feeling in the face. No deviation of the tongue. No deviation of the uvula. Normal gag reflex. Weakness in right arm 5/-5. Bilateral dysmetria , more severe in the right hand. Suffering from adiadochokinesis in right hand. Walking: ataxic, deviating to the right. Speech deficits.
Medical Test Results
Head CT without contrast medium from another hospital showed a hyperdense space-occupying lesion at the vertex of the cerebellum, measuring 14x23mm, larger on the right hand side with pressure on the fourth ventricle. No change was seen after injection of contrast medium. No significant change of size in ventricles, but showing in the temporal horns.
Treatment and Results
The patient went for tests with an opthalmologist who ruled out papilledema. Patient was in the care of the neurosurgery department who treated her with dexamethasone and Zantac, which improved her situation. Prof G. and Prof U. consulted with staff from the x-ray department, where it was decided that the patient needed a full ambulatory MRI, noting that depending on the results, she may be suffering from a bleeding cavernous angioma in her cerebellum.
However, there is no urgent need for emergency surgery.
The patient was released, pending clarification of her situation, in a good general condition with the following recommendations:
Recommendations on release
Follow-up by her doctor
Continued taking the prescribed medications as detailed
MRI as soon as possible
Return to neurosurgery clinic, by appointment following her MRI
In the case of any deterioration, go immediately to the Emergency Room.
Medication: 4mg x 2/day dexamethasone PO. Take as directed, reducing the dosage by 2mg every 2 days, until taking 2mg once a day.
150mg x 2/day PO Zantac. Stop taking this medication when you finish taking the dexamethasone.
On May an MRI test was performed:
MRI test – brain, including base of brain
Brain MRI with and without contrast
Cavernoma with sub-acute hemorrhage in the vermis, accompanied by venous angioma.
Slight edema round the cavernoma.
We reviewed the imaging on the patient. We agree that there is a cerebellar cavernous malformation in the vermis and our recommendation is to proceed with surgery via suboccipital craniotomy for resection of cavernous malformation. We feel because the patient is symptomatic, this further suggests that surgery is necessary. Naturally, we would be happy to perform this procedure at the Barrow Neurological Institute.